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Aesthetics Practice Today

Unsightly Bra Fat: Kybella Injections Dissolve Fat Cells Non-Surgically
August 17, 2016 8:45 AM by Mina Grasso
Fat bulging around the bra, in the front, back or around the arm pits, can be fashionably limiting to many women. This contributes to multiple wardrobe changes and frustration prior to an event. 

Lifestyle and genetics play a role in the way fat pockets are distributed in the body. Even people within their ideal weight have pockets of fat they can pinch and would love to eliminate or reduce. Bra fat happens to be a common area of increasing demand for fat reduction.

Kybella® injections used to dissolve fat are a non-surgical option to break up and destroy fat cells.  Kybella®, deoxycholic acid, is FDA approved to dissolve submental fat, also known as the "double chin." 

Deoxycholic acid is a naturally occurring molecule in the body that breaks down the fat that we ingest and aids in the absorption of fat. Once injected, a chemical reaction occurs and fat cells are destroyed-permanently. When Kybella® is injected under the chin, a noticeable reduction in fullness is noted and a more defined chin and jawline profile results. Kybella® has been successfully used as an effective solution to treat bra fat as well. 

A series of injections are recommended to obtain full results. The number of treatments and amount of solution used varies depending on the size of area of bra fat to be treated.

The demand for bra fat injections with Kybella® will continue to increase as patients become aware of the simple non-surgical office procedure to destroy unwanted fat pockets permanently.

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Hair Loss Treatment Strategies for Men and Women
July 20, 2016 8:19 AM by Mina Grasso
Psychological observational studies have consistently revealed that it takes only a few seconds to form an impression of a stranger from their facial appearance. Within a few seconds, impressions of personality traits and age are made.

Men and women with thinning hair or patterns of baldness are perceived to be older. Hair loss greatly impacts self-image, self-esteem, body image satisfaction and well-being. Hair loss progresses if left untreated. Some common causes of hair loss include, but are not limited to, genetics, testosterone conversion to DHT, other hormonal imbalances and physical and emotional stress.

More advanced strategies are available to slow the progression of hair loss and stimulate regeneration of hair:

1. Propecia (Finasteride)-Clinically proven to suppress DHT (Potential adverse sexual side effects and depression.)

2. Stimulate/regenerate hair follicles

  • Topical hair stimulating cocktails, which may include minoxidil, tretinoin, bimatoprost, herbal preparations
  • Laser Therapy-In office therapy or a home device
  • PRP/PRFM-Platelet rich plasma or platelet rich fibrin matrix use plasma that contains a concentrated amount of platelets, which function to repair tissue. PRP can be activated by the body's own collagen to release growth factors. When calcium chloride or thrombin is used to activate the plasma, platelets release growth factors more slowly. The slower release is felt to enhance the activity of the platelets for a longer period of time. When growth factors are released, they stimulate localized cells to repair and induce synthesis of healthy new tissue. When platelet rich plasma is used on the scalp, they stimulate dormant hair follicles to regenerate fuller, thicker and new healthy appearing hair.

3. Hair Transplantation-Over the years, technological advances have allowed men and women to experience more natural solutions than a few decades ago.

4. Hair Growth Supplements-Overall health is based on nutrients that we take in. A drug-free hair growth supplement with key nutrients called Viviscal Professional can help promote existing hair growth.

5. Combination Therapy-Depending on the degree of hair loss progression, more than one of these strategies can be used together.

Treatment strategies for hair loss should be considered with the first signs of hair loss. Clinical studies using these strategies have been proven to be beneficial and provide superior results when intervention happens in the early stages of hair loss.
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Developments for Platelet Rich Plasma in Aesthetics and Sexual Health
July 6, 2016 8:42 AM by Mina Grasso
Platelet rich plasma (PRP)  has been popularized in sports medicine by injured star athletes. PRP is used to augment the body's natural healing response. Supraphysiologic concentrations of platelet rich plasma are used to facilitate tissue repair, relieve symptoms of pain and improve function by modulating inflammation of injured tendons, ligaments and joints. 

Several fields of medicine, including wound care, ophthalmology, dentistry, maxillofacial surgery, urology, dermatology and cosmetic surgery, use this technology to treat various conditions in their specialties.

PRP has been part of our armamentarium for skin rejuvenation for several years. Patients frequently return for the brilliant "glow" they experience for a few days after their treatment. PRP can be delivered alone, injected directly into the skin, combined with hyaluronic acid or applied during microneedling or fractional CO2 laser resurfacing to enhance the rejuvenation. 

Platelet derived growth factors are released from the alpha granules in platelets after activation with thrombin, calcium or the tissue's own collagen. The growth factors and cytokines involved include the following:  

            BFGF-Basic fibroblast growth factor

            ECGF-Endothelial cell growth

            IGF-Insulin-like growth factor

            PD-EGF-Platelet-derived epidermal growth factor

            PDGF-Platelet-derived growth factor

            TGF-Transforming growth factor

            VEGF-Vascular endothelial growth factor

Cell proliferation, cell differentiation (unipotent stem cells) and angiogenesis occur.

Platelet rich plasma involves concentrating the platelets about one-and-a-half times for skin rejuvenation purposes. Various areas where skin rejuvenation is desired and PRP is used include the face, neck, décolleté, arms, legs and breasts. A recent article published in March 2016 in the Daily Mirror demonstrated a "Vampire Breast Lift" to benefit areas of irregularities and asymmetry of the breasts. PRP is used to improve the appearance of post-surgical scars as well as improve sensation.   Multiple studies are proving PRP to stimulate nerve regeneration.   

The latest exciting area in sexual health is PRP for vaginal rejuvenation called the O-Shot. It is effective in treating urinary incontinence as well as enhancing orgasms.

Patients are attached to platelet rich plasma procedures, because PRP utilizes their own natural regenerative abilities. Autologous PRP injected into tissue contributes to collagenesis, angiogenesis, as well as neurogenesis, resulting in healthier, more youthful tissue with improved sensation.

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Microblading for Better Brows
June 7, 2016 7:41 AM by Mina Grasso

The aesthetic industry has catered primarily to women, but a growing percentage of men are entering the aesthetic world every year. Men are spending more money on their appearance, as evidenced by increasing sales of grooming products for men and a greater number of aesthetic procedures purchased by men. Age-related concerns, wanting to stay competitive in the professional world, relationships and social media drive to men to seek procedures that help them maintain a youthful, well-groomed appearance.

By aesthetically evaluating the faces of men for various procedures over the years, I have learned that men have challenges with the appearance of their eyebrows just like women. Unlike men, it is socially acceptable and routine for women to cover up any abnormalities with makeup.

Permanent makeup has been an option for women to enhance the appearance of their eyebrows. Women may seek eyebrow enhancement to cover up a traumatic or surgical scar that has left a streak of hair loss within the brow. Permanent makeup is a solution for sparse brow hairs due to changes associated with aging or medical conditions. Some patients have very light colored eyebrow hairs and desire a more defined brow to frame for their eyes.

Today, procedures are available to promote a natural appearance. The microblading technique utilizes a refined approach delivered using a hand tool with needles finer than those of traditionally larger micropigmentation needles. Pigment is implanted into the skin using fine microstrokes. These are delivered one line at a time between existing hairs, following the man's hair pattern within the desired brow shape that best enhances his features. An average of 2 visits is recommended, but the pigemtn can be applied gradually and performed over more visits. The more natural appearance of the micrstrokes is attractive to men who want to enhance the appearance of their brows.

 

Recognizing the gender differences in anatomy with male brow position and shaping is key to delivering a successful cosmetic outcome with microblading. Men now have an option to enhance the appearance of their brows and feel confident that they look natural.

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Platelet Rich Plasma for Hair-Loss
May 20, 2016 10:02 AM by Mina Grasso
Hair loss can be devastating to both men and women, affecting self-esteem and self-confidence. Various genetic and environmental factors can cause hair-loss.  Environmental factors may include chemotherapy, diet & nutrition, stress, hormonal shifts and autoimmune disorders and various illnesses due to imbalances.

Treatment options can be found from "magical" topical lotions and potions, prescription medication and surgical procedures. A revolutionary procedure gaining popularity in aesthetics, orthopedic surgery and cardiac surgery is utilizing a patient's own rejuvenating properties with platelet rich plasma (PRP) for facial rejuvenation, tissue repair and healing. PRP is now being used as an option to rejuvenate the scalp.

The patient's blood is drawn directly into a special blood collection tube similar to getting blood drawn for laboratory tests. The tube of blood is placed into a centrifuge to allow separation of the red blood cells from the plasma. Topical application of the PRP can be applied after microneedling. As an alternative, the PRP can be injected directly into the scalp. The plasma contains the platelets that are very rich in growth factors. These growth factors stimulate stem cells to activate the proliferation phase of hair and stimulate production of new follicular units. It enhances a natural process of wound healing, resulting in repair and regeneration of cells. 

PRP can generate new hair growth; enhance hair transplant results for thicker, healthier hair growth. Unfortunately, for those patients with absence of hair follicles, PRP will not be likely to stimulate new hair growth. Healthy hair follicles need to be present.

PRP to the scalp for hair loss is well tolerated. A topical anesthetic is applied prior to the microneedling or injection of PRP.  A mild "sunburn" feel can be expected following the procedure.  Anti-inflammatories are not recommended since it may interfere with the natural healing process stimulated by the PRP. Multiple treatments may be needed before results are seen. Combination therapies with PRP are being performed in various clinics, and we will continue to learn more about effective treatments for hair restoration.

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Non-Surgical Liquid Facelifts for Men
May 10, 2016 9:25 AM by Mina Grasso

Athletic men often look older than their peers the same age due to facial volume loss. Some men with wrinkles between their brows and across their foreheads are often mistaken to appear angry or stressed. Volume loss under the eyes and mid face creates a "tired look." After hundreds of dollars spent on skin care products, men can appreciate some skin quality improvement, however, comments on appearing angry or tired, continue.

Men are discovering that others who have sought out non-surgical "liquid facelifts" benefit by looking 5-10+ years more youthful, less angry and refreshed. Liquid facelifts involves using a combination of facial injections with tissue fillers (Restylane, Juvederm, Voluma, Radiesse) or bio activators like Sculptra to restore volume loss combined with a neurotoxin (Botox, Dysport or Xeomin) to relax dynamic wrinkles. These injections are simple office procedures that take 10-30 minutes.

Social media has broadened the awareness of aesthetics in men. More men do their research for aesthetic interventions privately online. A majority of my male patients are brought in by their wives or girlfriends who have experienced benefits of liquid facelifts and want the same for their partner - to look more youthful, refreshed, less angry or less tired. Others come in willingly because they want to keep their appearance up for their partner.

It is critical to keep a man's anatomy and features in mind when treating with neuromodulators and replacing lost volume. Care is needed to avoid feminizing a man's features. Larger doses of neuromodulators are usually needed for men due to larger muscle mass. The masculine horizontal position of the brows must be preserved without creating a feminine arch or a lift of the brow. Men usually request the crow's feet lines to be softened rather that completely erased. 

Men have a more rhomboid shape to their face with more angles compared to a woman's triangular or heart shape with softer curves. An angled chin and jawline appears strong and masculine. The cheek height of a man is usually more medial than that of a woman's. 

Non-surgical "liquid facelifts appeals to men to contour and lift without incisions.  By minimizing lines, wrinkles and volume loss, liquid facelifts can provide men a refreshed, more youthful appearance while maintaining the harmonious proportions of a masculine face.

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Men Get Beach-Body Ready
April 26, 2016 9:51 AM by Mina Grasso
Men are becoming more focused on their appearance. This is especially true for those in a work environment where younger, equally qualified attractive males make for a more competitive arena. As a result there have been an increased number of male visits to online aesthetic websites, including online review sites of surgical and nonsurgical procedures. 

Going to the gym is no longer just a place to workout, but rather a place where men "check out" other men that are more fit and chiseled. The standard of male appearance in today's fitness setting has elevated. Males who are concerned with health and fitness often follow one or more fitness either personally or through social media. 

Teenagers and men learn about healthier eating, supplements and shakes to increase muscle mass with weight training or improve lean body mass. In addition, they are incorporating fitness routines to maximize the appearance of particular muscle groups to enhance the shape of their bodies and define musculature. 

CoolSculpt utilizes cryolipolysis to freeze unwanted fat bulges. The word is getting out about Coolscupt body shaping for men. The idea that Coolsculpt does not require incisions, needles or downtime is intriguing to men in or out of the fitness world. Freezing areas of unwanted fat has helped men achieve their body shape goals. 

Common areas that men seek treatment for, include love handles and abdomen. Men who have developed gynecomastia - "man boobs" now have a non-surgical option to reduce that fat that has accumulated on the breasts. When the fat layer over muscles is reduced, hard-earned muscles are revealed. Masculine muscle definition is the goal. Coolsculpt can help men achieve that goal faster.

In January of this year, Coolsculpt added a small applicator called Coolmini to treat submental fat - "double chin." A great majority of aesthetic patients surveyed reported that they were concerned with the appearance of their double chin. The fat freezing with the Coolmini is also non-surgical, does not involve incisions, needles or downtime. After the double chin is reduced, a man's neck can appear more youthful and the jawline angles and chin appear more defined and masculine. The Coolmini can also be used on smaller fat budges that we were able to treat prior due to larger applicators.

Men are more knowledgeable today about a healthy lifestyle, are energetic and motivated to achieve and maintain youthful vitality. With the variety of applicator shapes and sizes, the art of Coolsculpt is a tool that can be used to enhance efforts to obtain that "V" shaped, well-defined masculine physique. They can feel great and look amazing at the gym, beach and every day life.

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A Nose Job in 15 Minutes
April 12, 2016 9:25 AM by Mina Grasso
With the desire for aesthetic enhancement, there are many that have contemplated a surgical procedure called rhinoplasty. Rhinoplasty is one of the most popular plastic surgery procedures. However, some patients are not willing to undergo a surgical procedure with fear of pain and the downtime of redness, bruising and swelling. The cost of surgery prohibits others.

A non-surgical nose job, an alternative to surgery, is becoming more popular in the aesthetic world. Tissue fillers are used for nose augmentation to shape, reshape and enhance the appearance of a person's nose. It is an in-office procedure performed non-surgically with virtually no downtime. A non-surgical, non-invasive nose job or nose augmentation can take as little as 15 minutes and may last a year to two years or longer depending on the product used.

Some of the reasons patients present for a non-surgical nose job include:

  • Unhappy with the "hump" near the bridge of their nose
  • Desire to improve the shape and symmetry of their nose, trauma or genetics
  • Wants to avoid rhinoplasty or revision rhinoplasty
  • Feel their nose looks too big
  • Flat nasal bridge
  • Desire to have nasal tip raised or more defined

Just as other tissue fillers are used on various places on the face, variety of tissues have been used for nose reshaping. Tissue fillers used to augment the nose for non-surgical, non-invasive nose jobs include: Restylane, Resylane Lyft, Juvederm, Voluma - (hyaluronic acids), Radiesse (calcium hydroxyappetit), Bellafil (non-absorbable polymethylmethacrylate beads - PMMA microspheres) or a permanent product like Silicone.

When the undesired feature presents as "my nose looks too big now" or I want to get rid of the "hump" on my nose, adding volume to the nose or surrounding structures with tissue fillers can actually create a visual illusion of the nose appearing smaller. It's all about the golden ratio  - the proportions of beauty.

As noted above, many tissue filler options are available. I tend to favor the hyaluronic acid family particularly Restylane, Restylane Lyft or Voluma with their lifting and shaping properties. 

Another reason for favoring hyaluronic acid tissue fillers is that they are reversible with an enzyme called hyaluronidase. In cases where hyaluronidase is needed, results of the reversal can occur within minutes to a few hours. This is a critical factor; because many of the areas of the nose that are injected are adjacent to vascular structures that can create severe adverse complications if an intravascular injection were to occur. Therefore, it is important to seek a provider well trained and experienced in treating this area, taking all precautions to avoid complications and knows how to deal with complications urgently if they were ever to unfortunately to occur.

A topical anesthetic is applied prior to the procedure to reduce discomfort. The tissue filler is slowly injected into the area/s of concern and carefully molded.  Mild pressure is applied to reduce the risk of bruising followed by ice to reduce swelling. The results are instant. Patients are usually very pleased. There is minimal to no downtime. Mild swelling, tenderness or bruising may be experienced after the procedure. Patients can return to regular activities immediately.

Patients are usually amazed as to how quickly a non-surgical nose job can be performed and are excited about the results. Although it is temporary, they are very accepting of the need to return for maintenance in 9 -12 months or longer depending on the product used. In addition patents that may be ambivalent like the fact that the nose job can be reversed, and others view it as a stepping-stone to rhinoplasty.

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Non-Surgical Eye Rejuvenation
March 29, 2016 7:50 AM by Mina Grasso

When seeking rejuvenation, patients usually present with multiple concerns on various parts of their face. Rejuvenation around the eyes is what I like to start with. The eyes reflect personality and character of an individual. It is what engages individuals verbally and nonverbally. The eyes are the focal point of beauty. 

Changes in the skin, fat and bone contribute to the aging appearance of the peri-orbital area as well as changes in shape and features of the eyebrows. The aging process and the changes that occur as a result seem to detract from the beauty of the eyes. The following is a list of modalities that can enhance the appearance of the eyes.

Neuromodulaters: Botox, Dysport and Xeomin are often used to relax lines and wrinkles of the frown lines and crows feet. These neuromodulators are beneficial to help lift the brows and eyelids to some degree as well as shape the eye with strategic placement.  

Tissue fillers: Hyaluronic acids are the most common fillers used in the peri-orbital area. Restylane can reduce the hollow or "dark circle" appearance under the eyes and refresh the look of a person, helping them look less "tired" and more youthful. A variety of various hyaluronic acids can be used to soften lines such as the frown lines and crows feet when volume is needed. Fillers can also be used to shape the brows when placed carefully above the lateral orbital rim.

Permanent makeup: Eyeliner can create a more open look to the eyes and can enhance the appearance of the lashes. Eyebrows frame the eyes. Permanent makeup can be used to shape the brows with a solid powder look or using microblading to create fine hair strokes.

Latisse: Topical application of this solution can result in longer, fuller and darker lashes.

Cosmeceuticals: Antioxidants, vitamins, peptides, retinoids and other moisturizing agents can be used alone or in combination depending on the area to be used around the eyes. Sun protection is key to protecting further damage of the skin.

Lasers, Light Devices and Radiofrequency for Skin Rejuvenation: Quality of skin can be improved with non-invasive and minimally invasive devices. Intense pulsed light and other lasers for rejuvenation can treat sun damage, brown spots and redness. Fractional C02 can be used to stimulate collagen and improve elasticity and texture of skin surrounding the eyes. We have a multitude of options to reduce features that distract from the beauty of an individual's eyes. When these distractions are reduced or removed, that individual's focal point of beauty is usually revealed. You can't help engage with their eyes, they become more attractive. 

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Your Hands Can Make a Fashion Statement
March 14, 2016 2:12 PM by Mina Grasso
Fashion surrounds and influences our everyday life. Advertisements in magazines and commercials featuring fashionable clothing, jewelry, clutch purses, hair, makeup and more, which draws attention to the beauty of the part of the body that shows off these items.

Beauty and fashion go hand in hand. Makeup and photo editing can enhance images of the body part displaying the fashionable product. Thousands of dollars are spent on beauty products and aesthetic procedures to improve various areas of our bodies that we feel self-conscious about. With advances in aesthetic medicine, fashion that brings attention to various parts of our body can now be enjoyed. 

As we age, one of the most common areas that we become self-conscious about is the appearance of our hands. With the help of aesthetic advancements, our face can appear more youthful. However, our hands usually do not match and can give away our age. As our hands age, we begin to lose volume on the back of the hands which makes the veins begin to protrude and tendons become more visible making the back of the hands appear skeletal. In addition, due to loss of collagen and elasticity, the quality of the skin declines and skin irregularities and age spots start to appear.

Skincare products, skin rejuvenating lasers and light devices can be used on the hands as they are on the face, neck and chest to treat the quality of skin. The latest fashionable procedure is augmenting the back of the hands with volume as we have for years on the face. We can now turn back the signs of aging hands using a dermal filler called Radiesse. 

Radiesse, Ca HA (calcium hydroxyl apetite), is the first and only FDA approved product for hand augmentation to correct volume loss in the hands. Radiesse is bio-stimulatory filler that allows the skin on the hands to produce its own collagen. Lost volume is replaced, reducing the appearance of the protruding veins and prominent tendons. Due to the bio-stimulatory effect of improving collagen, patients usually report improvement in their skin quality.

Augmenting the hands with Radiesse involves a simple office procedure that usually can be completed in 10 minutes. The most common side effects include bruising, swelling and temporary lumpiness. This procedure appeals to many seeking aesthetic improvement of their hands. The results are immediate while the bio-stimulatory effects stimulate new collagen that continues to improve over time and results appear natural.  

Radiesse can be a game changer for many aging women embarrassed by their hands. Your hands do not have to reveal your age. You can now feel less self-conscious with more youthful and natural-looking hands, and feel confident making a fashion statement with your beautiful nails, jewelry or your clutch purse.

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Will Coolsculpt Tighten Skin?
March 7, 2016 2:55 PM by Mina Grasso
Body shaping procedures continue to increase in popularity. More options are becoming available for various parts of the body. However, it is becoming more complicated and confusing to consumers. 

One of the most popular aesthetic procedures that patients are seeking is Coolsculpting. Coolsculpting is a state of the art procedure using cryolipolysis that permanently destroys unwanted fat buldges such as the muffin top, thigh bulges, love handles, back and bra fat, arms and submental fat. It involves freezing fat cells without damage to the skin.

A common question that comes up during a consultation is: "will the Coolsculpt tighten my skin after the fat goes away?" When a patient comes in for a consultation for body shaping, Coolsculpt is definitely one of the options that is discussed as a non-surgical procedure. Some patients are seeking reduction of unwanted fat, others have issues of skin laxity while many patients want both addressed. 

The target of Coolsculpt is to reduce unwanted fat buldges. We do not promote Coolsculpt as a skin-tightening procedure. Patients may experience skin retraction as the fat cells are slowly reduced if they have good skin elasticity. We have seen skin retraction in majority of our patients and staff who have received Coolsculpt. I usually tell patients that skin tightening after the procedure depends on their skin elasticity. If patients have pre-existing skin looseness (laxity), it's important to set expectations that due to the loss of elasticity; the skin will probably not tighten as the fat is reduced. 

There have been reports of improvement in skin texture and skin laxity with Coolsculpt, but it's difficult to predict which patients will experience this improvement. Skin elasticity can vary with gender, age, history of sun exposure and hormonal balance. 

While consulting a patient for body contouring, it is important to determine what the patient's goals are. Coolsculpting can be combined with skin tightening procedures. Depending on the patient's condition, expectations and budget, a surgical referral may be the best choice. Patients can experience greater satisfaction when realistic expectations are set for Coolsculpting.

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Appropriate Diagnosis of “Brown Spots” & Treatment Plans
February 16, 2016 12:10 PM by Mina Grasso

Treatment of brown spots is the most common condition patients inquire about during a consultation. Appropriate assessment and diagnosis of what the patient calls "brown spots" is essential to developing an appropriate treatment plan.

Brown spots may include but are not limited to:

  • Birthmarks
  • Freckles
  • Brown patches
  • Melasma
  • Moles
  • PIH (post inflammatory hyperpigmentation) due to inflammation or trauma to the skin from acne, insect bites, abrasions, chemical peels, excision, laser procedures, etc.
  • Sebaceous hyperplasia
  • Solar keratosis
  • Skin tags
  • Skin cancers, etc.

Brown spots can be located various parts of the body, including, the face, trunk, legs, arms and hands.  

After a careful medical history is taken, suspicious lesions are ruled out that may require referral, treatment options can be discussed. Many treatment options are available for various conditions that patients call brown spots. These can include topical creams, surgical excision, electrocautery, chemical peels, photodynamic therapy, various laser procedures including vascular lasers, Q-switch using 532nm or 1064nm laser for pigment, broadband light, laser resurfacing, etc. 

Broadband or intense pulsed light, commonly referred to as photo- rejuvenation or foto-facial, is one of the most popular devices found in medical spas. Skin quality is improved with a series of treatments. One study conducted by a dermatologist showed more youthful gene patterns in skin biopsies of areas treated compared to untreated skin on the same individual. Due to the popularity of intense pulsed light (IPL), and the benefits patients have heard about, and seen, they may present to a clinic requesting a treatment believing that it will remove their spots as they have seen on their friends. In many patients a general improvement in the skin quality can be appreciated. However, it is not uncommon to have patient voice dissatisfaction after a series of treatments. "I spent all this money, and that spot is still there" is something we probably have heard over the years. No guarantees of treatment can ever be made, but some patients often require a combination of various modalities.

Melasma, a chronic hormone-related pigmentation is one of the most challenging conditions to treat. It is common to see practitioners increase energy delivery with lack of improvement of the pigmentation. This often results in worsening of the pigmentation due to excess inflammation in these individuals.

A treatment plan is crucial and must be thoroughly discussed. Realistic expectations must be set for patients regarding anticipated cost, number of treatments, and what to expect post procedure to plan for social downtime. In addition, limitations of particular treatments should be addressed.

During the initial evaluation of the patient's skin, standardized photographs and a VISIA skin analysis using a UV camera are great tools to document the baseline condition of the patient's skin and monitor the patient's progress throughout the treatment sessions. 

Appropriate diagnosis and a treatment plan with discussion on anticipated cost, number of treatments, social downtime and discussion of possible need for other modalities. This provides patients a sense of control that they have been informed with the options of treatment.  Realistic expectations are set with the plan developed together. There is less risk of surprises and leads to higher patient satisfaction.

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An Exciting 20 Years
February 4, 2016 11:18 AM by Mina Grasso
It is exciting to reflect back over the past 20 years on the evolution of non-surgical aesthetics in our practice.   Non-surgical aesthetic procedures now address fine lines, wrinkles, volume loss, irregular pigment, loose skin, veins, tattoo and hair removal, scar reduction, body contouring for fat and cellulite. In our practice we have incorporated bio-identical hormones and sexual health now to include vaginal rejuvenation.   A majority of these concerns patients have presented with are related to aging and hormones and an ongoing endeavor of anti-aging secrets to optimize beauty and vitality.  The following are a few highlights in the aesthetic trends in our practice.

"Injecting poison in your face?" Although still feared and avoided by many, Botox, initially was referred to, as a "poison" is now a more common household word. It becomes beauty maintenance for those who have experience the benefits, just as getting their hair colored or their teeth cleaned. Botox, Dysport and Xeomin are neuromodulators available in the US used to relax dynamic muscles that create wrinkles and even prevent wrinkles by blocking active contracting muscles. From what one patient may have feared Botox as a "poison" she didn't want in her face to "going to her Disneyland" when she comes in for her Botox or Dysport.

Liquid Facelift with soft tissue fillers: In the late 1990s some patients took advantage of bovine-based collagen injections to fill fine lines and wrinkles.  Patients who desired this had to undergo skin testing one month prior to treatment to test for allergy to bovine collagen. A great percentage of patients loved their results, however dissatisfied with the 3-month longevity of the product. In an effort to provide products that would last longer, cadaver particles, silicone and various other ingredients have been used to fill soft tissue as an alternative to fat transfer and surgical facial implants. 

Liquid Facelifts became more of a concept when Restylane, a non-animal based hyaluronic acid was FDA approved in the early 2000. Other products in the Restylane family were developed then the Juvederm family of products was introduced soon after. Radiesse, calcium hydroxylaptettit, tissue filler as well as a bio-activator was introduced soon after these products. Results of these products would be experienced immediately.  For those who were not needing immediate results and were enamored by the idea that their own collagen could be stimulated, Sculptra, poly-l lactic acid gained popularity. As new products were introduced, we continued to learn more about volume loss and the aging process. Skin changes, fat shrinkage and redistribution as well as bone loss were better understood in the aging face. 

We have evolved from chasing fine lines and wrinkles to a more global approach, understanding that a youthful face is more a triangle of beauty vs. the squared, aged look. The phi theory of proportions is used as we restore and enhance beauty. 

Non-surgical "liquid facelifts" are popular worldwide. It was surprising to see the term now offered as a medical spa service on cruise ships. 

Non-ablative, no downtime laser and light technologies: 20 years ago, non-ablative laser and light technologies were just being developed and we familiar with what was out there. Intense pulsed light (IPL) was our first non-ablative device is still one of the most popular technologies. Since then various non-ablative lasers using various wavelengths treating specific issues of the skin such as redness, broken capillaries, large pores, irregular texture and pigmentation have come to market. We as well as our patients have observed age reversing appearance of the skin. There was a study that actually proved to show via skin biopsies more youthful gene patterns of skin treated with a broadband light device vs. non-treated skin. Patients can benefit from anti-aging treatments over time with non-ablative technologies.

Minimally ablative laser procedures: No one likes downtime, but those who were willing to sacrifice 5-7 days of social downtime have experienced more dramatic results with certain minimally ablative lasers such as our lasers that target small veins on the face and pigmentation. For skin texture and rejuvenation, fractional non-ablative Fraxel was very popular. Some patients had more downtime than expected.

A few years later, we started to offer a minimally ablative fractional CO2 laser resurfacing to treat acne scars, surgical and traumatic scars and for general skin rejuvenation. We found that patients that although patients looked more red and swollen the first couple days, we had fewer side effects such hypo or hyperpigmentation, minimal to no acne breakout post procedure. Patients tolerated the procedure better with less discomfort. All skin types can be treated. We experienced higher patient satisfaction, improved results with fewer side effects. Fractional CO2 laser resurfacing is our go-to laser for those seeking more dramatic results for skin rejuvenation.

Skin Tightening: Over the years several technologies to treat various concerns for the face and body have been developed. Cellulite was one of the most challenging to improve. Endermologie, a cellulite solution using mechanical massage based on lymphatic drainage improved the appearance of cellulite temporarily. We still have patients who have experienced the benefits of Endermologie till request the treatment. Over the years, laser and radiofrequency energy was found to enhance the effects of mechanical massage and Velasmooth, Tri-Active and Viora Reaction were introduced to the practice. These devices offered temporary relief of cellulite after a series of t1-2 times a week sessions. The most recent addition for cellulite is ThermiTight RF injectable radiofrequency offers a longer 1-2 year solution to cellulite after one session. 

We have addressed skin laxity in the face and body with Thermage and Viora radiofrequency without downtime. Now a minimally invasive temperature control system utilizes higher energy levels of radiofrequency and provides longer lasting results. Injectable RF - ThermiTight can address skin laxity in the jowls and neck, arms, abdomen, thighs and loose skin over the knees. Radiofrequency triggers neocollagenesis, which helps firm, tighten, lifts and tones the skin. Higher temperature range can produce more neocollagenesis.

Body Contouring and Fat Reduction: Laser lipolysis with small areas of liposuction were performed years ago. We abandoned this to meet our patient's demand for no downtime options. Coolsculpt technology utilizes cryolipolysis to freeze fat cells. Fat cells are destroyed controlled freezing of fat using a specific applicator for the area treated. Cryolipolysis results in apoptosis of fat cells. Initially we had an applicator only for the small areas of the abdomen. Over time specially curved shaped applicators to treat the love handles and back fat as well as larger applicators for larger areas of the abdomen were made available. Several years later an applicator for saddlebags became available as well as a smaller applicator that we can use for inner thighs, upper arms, anterior and posterior axillary fat.

Before the end of 2015 a long-awaited applicator, the Coolmini, was brought to market. It was developed to treat submental fat. The "double chin" is a concern for approximately 67% of all aesthetic patients.

This year, 2016, brings another promising solution to the "double chin" fat. Kybella (deoxycholic acid) is a chemical ingredient we used in our mesotherapy formulation to dissolve fat for various areas of the body years ago. We, like other practices, abandoned the practice of mesotherapy. Our reasons included lack of standardizations of recommended formulas, severe bruising and swelling. Skin necrosis had been one of the worst adverse events we encountered. Kybella is standardized and specific protocols have been developed for safety and efficacy. We have experienced great results and are proud to offer this minimal to no downtime solution for the "double chin."

Anti-Aging: For decades people have searched for various anti-aging remedies. Skin care, peels, laser have claimed to produce age-reversing results. Platelet rich plasma (PRP) has created quite a buzz during the past decade. PRP utilizes a patient's own plasma to regenerate and repair exposed tissue. We commonly apply the PRP immediately after procedures such as Dermapen (microneedling) and fractional CO2 laser resurfacing.

As part of an aesthetic practice we have incorporated bio-identical hormones (BHRT) and nutritional counseling. Nutrition and hormone balance plays a big role in overall skin health and vitality.

In providing hormone therapy, sexual health issues are frequently discussed. The most recent aesthetic procedure added to the practice is ThermiVA, a non-surgical, no-downtime vaginal rejuvenation that utilizes radiofrequency to tighten skin laxity of the vulva, and when used in the vaginal canal results in tightening of muscles and increases vaginal lubrication as a result of thermal neurogenesis. Patients report improved issues with incontinence and sexual health. 

The evolution of our aesthetic practice over the past 20 years truly has been patient driven. Patients seek and benefit from anti-aging, non-surgical, minimal to no downtime procedures that fit their busy lifestyle.

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Skin Quality Improvement
January 19, 2016 8:18 AM by Mina Grasso
Skin quality improvement can be accomplished in a variety of methods. Skin is the first line of beauty. It is one of the first clues to our age and general health. Skin hydration, reflection of light, tone, texture, pigmentation, fine lines and wrinkles can be addressed with specific therapeutic, cosmeceutical and prescription skin care ingredients to enhance the health of the skin. Combined with laser and light technologies and/or chemical peels, skin quality can be further restored. As we continue to age and our skin is subject to environmental factors such as sun exposure, changes in humidity, free radicals and hormonal shifts, maintenance is required. Prevention and protection such as minimizing exposure and routine use sun protection and antioxidants in skin care are key to giving us the best chance to maintain the beneficial results.

Skin tightening for laxity can be addressed with non-surgical skin tightening procedure using radiofrequency technology (Thermage, Viora) or ultrasound technology. ThermiTight Injectable RF a minimally invasive procedure involving controlled, but higher energy radiofrequency delivered under the skin can address skin laxity for the jowls and neck. Those with more severe laxity seek surgical options out.

Volume loss replacement can be addressed using a global approach. The entire shape of the face changes due to fat loss or redistribution, bone changes and skin factors as mentioned above. Tissue fillers and collagen stimulators help to address and restore facial shape and fullness that are associated with a more youthful face. 

Tissue fillers commonly used include, but not limited to hyaluronic acids in the Restylane and Juvederm family. Radiesse, calcium hydroxyapatite, is both a soft tissue filler and collagen stimulator.

Sculptra, poly L-lactic acid, is a very safe product that is often used in implants and dissolvable sutures. Sculptra promotes production of natural collagen in the treated areas. Sculptra gradually corrects the recession of the skin or adds volume to areas of bone loss such as around the cheeks, temples chin and along the jawline. Sculptra is used to volumize and provide structural support. Sculptra creates a scaffolding of collagen with long-lasting results.

Natural proportions of a beautiful face can be refined and restored with volume replacement. Facial volume can help maintain the triangle of youth while the aging face normally would descend to a more square shape with aging redistribution of facial structures.

Fat Reduction in the Neck

In aesthetic surveys, 67% of consumers are bothered by submental fat. Patients look and feel older with greater fullness in their neck. Kybella is the first and only FDA-approved nonsurgical treatment that contours and improves the appearance of submental fullness. Kybella (deoxycholic acid) is a solution used to treat moderate to severe fat submental fat. When Kybella is injected into the neck fat, it physically destroys fat cells. Multiple injections are used in a single treatment session. Kybella is a simple in-office procedure that typically takes as little as 15 to 20 minutes may be required for desired results

CoolSculpt CoolMini - Cryolipolysis has been an effective non-invasive method that has been used for several years to sculpt the body by destroying fat cells by freezing the fat under a carefully controlled condition. The neck skin and fat is sucked into a small chamber for an hour while the fat is treated with controlled freezing. Apoptosis is focused directly at selective fat cells while preserving the surrounding skin. "Prolonged, controlled local tissue cooling can induce selective fat cell reduction and subsequent loss of subcutaneous fat, without damaging the overlying skin".

Develop a Maintenance Plan for Facial Rejuvenation

Many of these procedures work synergistically. Multiple sessions may be required for the desired results. Continued treatment can develop cumulative effects. As a result patients can look more youthful today than they did 5-10 years ago. With increasing sophistication in clinical photography we are becoming more aware of the secrets that are refining, restoring and reversing the signs of aging.
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What’s Hot in 2016
January 5, 2016 1:50 PM by Mina Grasso
Aesthetic concerns of women go beyond the face and common body treatments.  Over the last decade focus on the body with term "Mommy Makeover" has increased in popularity. This year women will seek solutions to restore feminine youthfulness. "Vaginal Rejuvenation" has entered the world of aesthetics. The topic is gaining awareness worldwide.

Many don't bother reporting issues because they have accepted it as part of the aging process. Others due to cultural reasons are horrified to consider discussion or deny they have any issues. When bringing up the topic usually with their GYN practitioner, overactive bladder and stress incontinence are usually more acceptable topics to start the discussion. This may lead to discussion of vaginal laxity or looseness and other vulvovaginal issues like atrophy lack of lubrication - dryness especially in the perimenopausal and menopausal ages. Orgasmic disorders and sexual desire are issues rarely brought up by patients largely due to acceptance with aging and hormonal decline. Family practice, women's health and other specialties and now the world of aesthetics can provide options for treatment to optimize sexual health.

ThermiVA is a revolutionary solution to restore feminine youthfulness for our patients who desire cosmetic enhancement of the vulva and have experienced the additional benefits of resolving their incontinence and have reported improved orgasms. 

ThermiVA is a non-invasive procedure that requires absolutely no downtime. It utilizes a controlled radiofrequency platform. A small applicator with a temperature sensor at the tip is used to heat the tissue of the vulva and the vaginal canal. It uses temperature as a clinical endpoint to smooth skin and shrink mucosa. Heating the skin and mucosa promotes immediate contraction of collagen, immediate collagen remodeling and elasticity, and long term stimulation in producing new collagen. It is believed that incontinence and tightening of the pelvic floor and the heat of the radiofrequency to stimulate neuromodulation improve sexual function.

ThermiVA is the current WOW of the practice. Patients describe the procedure with the sensation of a hot stone massage on the vulva and report a pressure sensation with virtually no pain in the vaginal canal. No pain medication or anesthetic is required. With more patients demanding non-surgical options that provide long-lasting results without downtime, patient satisfaction is extremely high.

Patient testimonials:

"I am a 65 yr old woman that had experienced a decrease in sensation during sexual activity. My orgasms were lackluster if they even occurred. I heard of the ThermiVa procedure and had my first treatment 7 weeks ago. It was a short and comfortable procedure in a most aesthetic environment. There is no down time with this procedure so was anxious to see results.  All I can say is "WOW." All of my vaginal nerve cells came alive. It was like having intercourse 20 years ago. A few weeks ago, I had the second procedure with this treatment. I noticed tightening of both the external labia and vulva. The sensation is phenomenal and I am truly satisfied."

"Walking, laughing, sneezing, coughing frequently caught me in the embarrassing situation of uncontrollable dribbling. After the 1st of 3 ThermiVa treatments the improvement was surprising. I didn't expect results to occur within hours of the procedure, but they were. I'm able to "clench" and stop mid-stream (just as a test).  The month after the 1st treatment has been a relief from worry because I know I can control and prevent leakage."

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    Occupation: Physician Assistant/Nurse Practitioner
    Setting: Miami & Upland, Calif.
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